S 2397 (2) -- —-APPLICANTTO-FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL.
BUILDING ADDRESS:__ �a + A
BUILDING PROJECT IDENTIFICATION 10551
Jd JU
1 o S/ A , I����y jSNARY NO. APPILIIICCAT10NSURMI'17AL DATWNERS NAME: ^%�50� ,VPF}ry��D_/���C•I CO R�f-1'OR'S M LIC NO /`7 —TLFL_ VK v ,N CM ROLof
ARCHITECT/T;NGINEER: LIC NO: AEl
C� �5 t( -r s
v
77b u l-.S�
COMPACT: PHONE:
BUILDING PERMIT INFO
�� P `1 S _D� ❑ Consul[am Fees Paid by Applicant(Initial) BLDG ELECT pLu❑MD MIiC- 11
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT b/
I hereby affirm Ih:a 1 am licensed under pr"i";mn,of chapter 9(emnmem;ns FEE JOB DESCRIPTION
�O�DMZ with Section7M)),,fDivininn 3 aflhe BOsines."and Profession.Ctde,and my littn"r is
QUin full forte and eRtt �q,,,,,, PERMIT ISSUANCE RESIDENTIAL'
U License Cleve ��� LIaN�V�(�� ❑SF'DWL ❑KITCHEN REMODEL
vFi6L Dae �M14V []ADDITION--- —.-a--Cantracmr AI'I'LIANCEti-RF_SIDEiNT1Al. ❑PLUMBING RE-PIPE
I- '. ARCHITECTS DECLARATION
OZ-
Z`Z I understand my 11tal,shall he uwd.s,Iblic rcc ads I PANEL; ❑MULTI-UNIT ❑ L.
STRUCTURA
MODIFICATION
F.'�-. 'E --a-dProf"natiel UP'T02W AMPS 22ZO
El INTERIOR 11 CHIMNEY REPAIR
201-1(MDAMPS IMPROVEMENT SWIMMING POOLS
Yw, OWNER-BUILDER DECLARATION Iylik l(((IgMPS
Q I hereby ul)irm that I nm exempt tmm�the Convamar's License Law far the ❑OATH REMODEVREPAIR DEMOLITION
p]'3,F following reason.(Section 7131.5.liuviness and Pmfcssinm Code:Any city or county SIGNS ELECTRICAL ❑OTHER
Is-
F- O oo which acquires b Permit to camtmcm,alter.improve,demolish,or repair any strnurc
yg nnitaissuance.at"orequireuheapplicamfnrsueh mhmrleasigneeamtnmm to t AC�--
0v�� that he is licensed Ito the SPI?CIAL CIRCUIT/MISC. /.G�r
kyQ� pScsuan pnDoInio ofthe Contractors Lic,nseLime,CORE or N 1
25 MQ
(commencing with Section]Ip0)Of Division LNthe lWsiness end Professions Calelnr TEMP.MEIF,R OR PULE INS'C OMM R IAI-
66 o yy that he is exempt therefrom and the heads for the alleged exemption.Any violation of
Q:N Section 71131.5 by nny applicant for a permit nubjects the applicant Io a civil penalty of POWI7R DEVICES ❑NEW BLDG/ADDIT'ION ❑DEMOLITION
t marc than five hundred Jollam(S5W). ❑TENANT ❑FOOD SERVICE
=0 ❑ I,as owner of the pmPeny,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC I IMPROVEMENT
^$ MINA,,thework.and thenfuctum is nntimendcNormffered Ed,hair Ume VIH4,Business ❑OT'HF.R
L 3 and Promotions CME:The Contractor's License Law dttes not apply um an owner Of OIJ'I'LITS-SwITCHIS-FIXTURES
Property who builds or imprmxs thereon,amt who dace such work him"elfoa through
his Own employees,provided that.such improvements arc nut intended or offered for NEW RESIDENTIAL ELEL='R SQ FT.
o,da.IL however.me buildingm improvement is cold withimmoycmofromplamm.ase SQ.F'I'.RIX)H AREA S/SQ.FT.
owner builder will have the burden of proving that he did not build m improve for pur-
pseof"ulc). ,
❑1,ax owner OI'the pmpeny,am exclusively cantering with Recused commeturs m TOTAI 2
nsmrct tae Prnjmt(Stt.]IW,Hueiness and Prfessiom Calc:)She Contmcme,Li- t
cense Law does not apply It,an owner Ofpmpery who builds or improve,thereon,and QTY, PLUMBING PERMIT
who contracts for rch plool"t,wilh n cnntmctor(s)licensed Pullman to me Cnntmemr's FEE
License Law.
❑ I am exempt under Sec. ,B&PC for reason PERMIT ISSUANCE
Owner DateACI HR-DRAIN&VENT-WAI'Iin(EAI V UA'f10N
WORKF,R'S COMPENSATION DECLARATION BACK FLOW PRCTECT.DEVICE
I hereby affirm under Penalty mf perjury one of the following declarmions:
❑ Uove and will maintain a Certifiable of Con.wal ms elf-insure far Worker's Ciampi DRAINS-FLOOR,ROOF,AREA,COND,
ration,as provided for by Section Thin of the labor Code,for he performance of the STORIES TYPE.CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
have and will maintain Workers Compensation Insurance,its required by Nation
]00 o1 the loam Cork,ho rhe Perfmmanceofthe work for which his pend,is issued. GAS-U.S ,
My We,cI imapanciation Inasaor c 'grand Policy umber vm: OCCGROUP ppN
Currier. cc
No.: 67
GAS-IiAS AVE
___C�I���22T__I ICATB OF P.XEMPI'ION PROM WORKERS'�Q
COMPENSATION INSURANCE GREASEANI L WASTE INTERCEPTOR
('Ibis section dead not to,completed iftha permit is forme,hundred dolhm(S l llol / BUILDING DIVISION FEES
Or less.) GRIiA SETS - -- - --
Iunify thm inthe pcAomuncc ofthe work forwhich Bis permit is iuuM,I shall PLANCHECK PEE
not employ any grown,in any manner so as to become.whjecuo the Workeri Comon- SEWER-S By-STORM EA.2Dm FT.
Oz station Law"Of Cul i fomia.Date ENERGY FT,E
Z Applicant WATER If" 17 ENT/ELECTR
NOTICE TO APPLICANT:If,after making this Cerifirde of Exemption,you shouldGRADING FRE
F h WATER SYS'E1g711tEiCTI=--
become
a > ith comp to the Wnrkcls COmFcns mi, rood,Provisionsof of the Lubar Cale,you must SOILS PEE
0. Q forthwith comply with such provisions nr mi"pcamit shall he deemed revoked.
WATER SERVICE
z CONSTRUCTION LENDING AGENCY NF.WkESIDIiNT1AL1'hMR. p. T. PAID
U I herebyuffirmthm naris aconadetion lenditgagency for heperldrtnbnce of RtteiptM
P:
the work for which this permit is issued(Sec.3097,Civ.C.)
0 U Lenders Name
4i1 Under's Address TOTAL TOTAL:
p 1 cetify that 1 have read this application and sum that the above information is BUILDING FE-11
UZE correctl agree to comply with all city and county oMinances and state laws relating it) QTY MECHANICAL PERMIT FEE
huildingeoostructimn,and hereby amhorlee representatives ofmis city to enter upon the SEISMIC
aM1nve-n o Bonro
ed progeny for inspection purposes. r
(We)agree m save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC 'E 3 O
liabilitie,mar a Bents,ensu"amt expense which nny in nny way mnrue against said City
in consequence of the gaming of this Permit. ALTER OR ADD TO MIiCH. PLUMBING .E
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT CEO MIXED CFM)
SOURCE REGULATIONS. MECHANICAL 0
AIR HANDLING UNIT(OVER 111,0(10 CF M) CONSTRUCTION TAX
Stgnamrc Of Applman(Contrdctar [)are EXHAUST HOOF)WdUUM
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or l umre building occupant store mhandle hamNons.amain) HEATING UNI'P(To 100,00)BTU) 1 Z��
as defined by the C.,mrO Municipal Code,Chaplet 9.12,and the Health and Safety
Cuda,$01un 25532(a)'1 HEATING UNIT(OVER IOI,old ED U)
❑Yes 11j117
VENTILATION FAN(SINGLE BESIDE PAID
Will the applicant or future hailding,,Oaupenu use ripinnamt or devices which Date Raeim M
emit haeuNous air comouramals as relined by the Bay Area Air Quality Management BOILER-COMP(3HPOR IW,DOBTU)
`District!
❑Yes y BOILER-COMP(OVER 100,000 BTU) If
1 have read the"Miles mamdals mlmocmems..it,Chapter 6.95 of the Cali- J
AIR CONDITIONER ! to 7 s
fomia Health&Safety Cale,Sections 25505,25533 and 25534.1 undersmnd that if the ISSUANCE DATE
huilJingJceenrncurentlyhaveatenant.thmitientyresrym."ibilitymnomifythercwpnnl NEW RESIDENT'JAL MECH. SQ.FT.
OF the ems which m s be et Private
orb Cenilcam of tkeu
Corrector authorimd itgent 'a nr
SAT ISSUED BY:
OFFICE